Provider Demographics
NPI:1134107766
Name:IVAN, RHONDA JANIECE (NP NURSE PRACTITIONE)
Entity Type:Individual
Prefix:
First Name:RHONDA
Middle Name:JANIECE
Last Name:IVAN
Suffix:
Gender:F
Credentials:NP NURSE PRACTITIONE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5400 MACKINAW RD
Mailing Address - Street 2:STE 6100
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48604-9515
Mailing Address - Country:US
Mailing Address - Phone:989-792-3100
Mailing Address - Fax:989-792-9860
Practice Address - Street 1:5400 MACKINAW RD
Practice Address - Street 2:STE 6100
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48604-9515
Practice Address - Country:US
Practice Address - Phone:989-792-3100
Practice Address - Fax:989-792-9860
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704135668363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4223256Medicaid
MI4223256Medicaid